Citation Nr: 21013148 Decision Date: 03/08/21 Archive Date: 03/08/21 DOCKET NO. 17-17 116 DATE: March 8, 2021 REMANDED Entitlement to service connection for a psychiatric disability, to include schizophrenia, is remanded. REASONS FOR REMAND The Veteran had active military service from March 1991 to March 1993. This matter comes before the Board of Veterans’ Appeals (Board) from a February 2015 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO). In November 2019, the Veteran testified before the undersigned Veterans Law Judge (VLJ). A hearing transcript is associated with the record. In January 2020, the Board remanded the Veteran’s claim. Entitlement to service connection for a psychiatric disability, to include paranoid schizophrenia. To ensure that VA has met its duty to assist, remand is again necessary. Stegall v. West, 11 Vet. App. 268, 270-71 (1998). The Veteran, and his representative, contends that he had a preexisting mental disorder and that it was aggravated during service. See Hearing Transcript (November 2019). He testified that the lack of in-service treatment for his preexisting mental disorder aggravated it. The Veteran’s representative directs the Board to in-service incidents of (1) drunk and disorderly conduct, and (2) sexual assault and criminal confinement. While the Veteran has undergone a VA examination after the January 2020 remand, it is inadequate. Where VA provides an examination or obtains an opinion, it must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). First, the examination does not provide the answers to the question posed by the Board’s January 2020 remand. See Stegall, supra. The Board requested a medical opinion that expressly addresses the following: (a) Is it clear and unmistakable (obvious, manifest, and undebatable) that the paranoid schizophrenia (or other acquired psychiatric disorder) preexisted active service? (b) If so, is it clear and unmistakable (obvious, manifest, and undebatable) that the paranoid schizophrenia (or other acquired psychiatric disorder) WAS NOT aggravated during service; or whether it is clear and unmistakable (obvious, manifest, and undebatable) that any increase in service was due to the natural progress? (c) If paranoid schizophrenia (or other acquired psychiatric disorder) did not preexist service, is it at least as likely as not (a probability of 50 percent or greater) that it had its onset during active service or otherwise related to an in-service injury, event, or disease. See BVA Decision (January 2020). A February 2020 VA examination diagnosed the Veteran with paranoid schizophrenia. At this time, the Veteran reported childhood/pre-military traumas (e.g. placement in an orphanage at age 9; physical, emotional, and sexual abuse by his mother and her friends; bullying by peers; and physical abuse after his adoption at age 11 by his adoptive father). It was noted that the “Veteran's childhood/pre-military mental health issues, if any, including ADD, dyslexia, any other MH diagnosis: Veteran believes that he was given psychiatric medications including Ritalin and Thorazine while living in the orphanage.” By history, while in the military, he was denied his request of psychiatric care, but noted that he received “counseling for one or two sessions when an officer had him do so. The focus at that time was on alcohol abuse. He states that he asked for mental health services at that time but, he reports, he decided not to follow-through for fear of negative career implications.” The Veteran reported that he was a delusional paranoid schizophrenic, had attempted suicide by drug overdose in 2010 resulting in involuntary hospitalization, and that he cannot recall how many times he had in-patient care. The Veteran reported that, during his military service, he was convicted of drunk and disorderly conduct; and that he was “jailed on charges of rape which resulted in two year’s incarceration.” He stated that he was arrested in 1995 for battery, but reports only “probation for unpaid traffic fines” He stated he abused substances prior to, during, and after his military service although he noted use of cocaine and heavier use of alcohol after miliary service. The examiner remarked that: Paranoid schizophrenia is a heritable disorder that can be triggered or exacerbated by psychosocial factors such as the levels of abuse this veteran reports experiencing in childhood. The genetic history reportedly includes behaviors suggestive of schizophrenia in several of this veteran's relatives. While the course of the illness can vary from person to person it is not uncommon for patients to experience a waxing and waning course with episodes of relative quiescence and episodes of exacerbation such as those described by this veteran. The associated February 2020 VA medical opinion address direct service connection only and reflects that it “is less likely than not that this veteran’s paranoid schizophrenia is incurred in or was exacerbate [sic].” See C&P Exam (February 2020). The rationale was: Neither the record, nor the veteran's self-report include references to mental health services other than those pertaining to alcohol abuse. He describes in detail the symptoms of, and treatment for the illness dating back to early childhood. Although he believes the disorder was less virulent just prior to his enlistment the natural course of the disorder accounts for the ups and downs in virulence. He readily acknowledges using intoxicants while in service. These too would likely cause disinhibition and promote symptom exacerbation The opinion does not substantially comply with the Board’s prior remand directives. A remand by the Board imposes upon the Secretary of VA a concomitant duty to ensure compliance with the terms of the remand. Where remand orders of the Board are not complied with, the Board errs in failing to ensure compliance. Stegall v. West, 11 Vet. App. 268 (1998). Lastly with regard to records, review of VA treatment records reveals that non-VA treatment records have been scanned into the VA medical records systems through VistA imaging, although references to these records do not clearly identify whether they are relevant this particular claim. See CAPRI (January 2020). Remand is necessary to associate these records with the claims file. See Sullivan v. McDonald, 815 F.3d 786 (Fed. Cir. 2016). The matter is REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from January 2020 to the Present, and obtain copies of all documents in VistA imaging for inclusion in his claims file. 2. Thereafter, obtain an addendum opinion from an appropriate clinician to determine the nature and etiology of the Veteran’s diagnosed schizophrenia. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. The medical opinion should, among other things, include a discussion of (1) the Veteran’s documented history and assertions, and (2) the in-service incidents of drunk and disorderly conduct and sexual assault and criminal confinement. The examiner should provide a medical opinion that expressly addresses the following questions in this order: (a) Is it clear and unmistakable (obvious, manifest, and undebatable) that the Veteran’s schizophrenia preexisted active service? (b) If so, is it clear and unmistakable (obvious, manifest, and undebatable) that the Veteran’s schizophrenia WAS NOT aggravated during service; or whether it is clear and unmistakable (obvious, manifest, and undebatable) that any increase in service was due to the natural progress? (c) ONLY if schizophrenia did not preexist service, is it at least as likely as not (a probability of 50 percent or greater) that it had its onset during active service or within one year after service discharge; or is otherwise related to an in-service injury, event, or disease to include the “confines of the ship” as reported by the Veteran at his November 2019 Board hearing? 3. Ensure that the VA medical opinions obtained include a complete rationale for the conclusions reached. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. M. Pesin The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.